Inpatient and Partial Hospital Care
In Year 2, residents devote approximately 30 hours per week for eight months toward inpatient, acute residential and partial hospital care at McLean and the Franciscan Children’s Hospitals. In recent years, there have been changes in hospital-based evaluations and treatment nationwide. Under the leadership of Joseph Gold, M.D., Director of the Child and Adolescent Program at McLean, the program has made numerous modifications in its health care system to provide the highest quality of care for its youth and families. Guiding principles in implementing these changes have been utilization of a strong multidisciplinary team, provision of a continuum of care involving close collaboration between inpatient care and use of partial hospital programs, recreational facilities, outpatient clinics, psychoeducational programs and the Arlington Day School, and development of close working relationships with community public sector agencies, residential treatment programs and health maintenance organizations. The essence of care is continuity of treatment. Thus, the goal of the hospital care rotation is for the resident to learn principles of evaluation, multimodal treatment and disposition planning in the context of a continuous care plan. All of these principles and skills are taught through the highly supervised hospital care rotations.

The judicious use of the McLean inpatient facilities has enabled the development of short-term treatment plans that otherwise could not have been formulated and implemented in the high-risk population that McLean serves.

Hospitalization has enabled the inpatient service to diagnose and treat children and families when other resources have failed. Hospitalization has permitted the unit to collect essential diagnostic and treatment data through detailed observations of patient and family. Hospitalization has provided for the child, perhaps for the first time, a structured, protective, holding and limiting social and educational environment.

Care in the hospital settings facilitate efficient and effective evaluation and treatment, when there has been such disorganization in the family that child and family have been unavailable to describe, demonstrate and consider their difficulties. Hospitalization has been critical when the behavior or feelings of child or family members became unmanageable and presented a threat to the safety of person or property in family and community.

While on their four-month, 30-hour per week inpatient rotation at Franciscan Children’s Hospital, second-year residents will provide intensive evaluation and treatment planning for latency-age children and their families. At Franciscan’s, residents provide coverage for admissions during the day on a rotating basis. They follow two or three cases as providers of comprehensive treatment for children, adolescents and families, along with members of the multidisciplinary team and under the supervision of attending staff child psychiatrists, Drs. Thrassos Calligas and Andrew Stromberg. As the physicians responsible and accountable for the planning, multimodal treatment, disposition and aftercare of their patients, the residents participate in the multidisciplinary team that synthesizes the psychiatric, pediatric/neurologic, psychoeducational and community resources. Treatment includes psychotherapy, pharmacotherapy, psychoeducation, family therapy, cognitive behavior therapy, group therapies, activity therapy and cognitive control therapy. In addition to child psychiatry attending supervision by the physician-in-charge (PIC) overseeing each case, residents have additional supervision on the inpatient unit for psychopharmacology, group therapy and behavior and cognitive therapy, as needed. The residents on the unit attend a weekly multidisciplinary case conference, daily rounds on all patients, community meetings and treatment review conferences.

Residents will spend 30 hours/week for four months in the McLean partial hospital and acute residential treatment (ART) rotation. Dr. Michael Rater is the Medical Director and Drs. Mark Alexakos and Blaise Aquirre are attending psychiatrists. All three provide supervision for the residents. The ART and Partial Hospital Program offers an intensive treatment experience for adolescents who do not require inpatient hospitalization but need a more structured, in-depth form of treatment than is possible in an outpatient setting. The program treats moderately to severely disturbed adolescents diagnosed with a range of psychiatric disorders, including mood and anxiety disorders, severe character disorders, substance abuse and post traumatic stress disorders. The mission of the program is to increase resilience and functioning within the family and community.

Participants in the partial hospital program follow a core schedule from 9:00 a.m. to 3:00 p.m., including individual, family and group psychotherapy. Additional activities available after that time can serve as after-school programs, when appropriate. Participants have access to psychotherapy groups and activities that cover academic performance, addiction and recovery, parenting, arts and creative activities such as cooking, young men’s and young women’s issues and sports. Partial hospitalization is cost effective and allows for a deliberate process of integration into the community, which many patients find beneficial.

As an adjunct to the Partial Hospital Program, acute residential services are available to adolescents who require 24-hour care. This is an unlocked setting with a more relaxed structure than an inpatient unit. It is licensed by the Office for Children. The weekday hours of operation for the residential program are from 3:00 p.m. to 9:00 a.m. the following morning. There is 24-hour coverage on weekends and holidays. The Acute Residential Treatment Program (ART) is housed on two floors of East House at McLean Hospital. The second floor program is designed to accommodate patients who require relatively short courses of residential or day program treatment. These patients are involved primarily in the substance abuse program. East House II has a typical census of 10 patients. The first floor program is comprised of patients awaiting residential placement or patients who require didactic behavior skills training. For those patients in the skills track, lengths of stay rarely exceed one month.

While in the partial hospital and acute residential rotation, residents will serve as psychiatrists, in an intensive multidisciplinary milieu. They are assigned four patients at a time. As the physician responsible for the planning, treatment, deposition and aftercare of patients, the resident provides the synthesis of the psychiatric, pediatric/neurological, psychoeducational and community resources. Typically, residents lead, or co-lead, two small psychotherapy groups a week, two specialty groups (e.g., trauma, substance abuse, psychodrama) and attend one community meeting per week. Residents are an integral part of the milieu team. They spend one hour per week in supervision with the Director, Dr. Rater, one hour per week with the leader of the Trauma Program, Dr. Cynthia Kaplan, one hour per week with the head of the Substance Abuse Track, Dr. John Rodolico, and one hour per week in individual psychopharmacology supervision with a Board certified child psychiatrist. The group supervision is a component of the required Milieu Psychotherapy Seminar, under the direction of Dr. Joseph Powers. The residents attend a weekly case conference seminar, where expert consultants are invited in to discuss the treatment of one of the patients on the unit. There are staff meetings three times per week. There are weekly team conferences and diagnostic review conferences in which residents participate.

During their second year, residents are associated with the psychoeducation program in both the inpatient and partial hospital programs, which provide psychological and educational assessment and treatment through individual and classroom work. Behavior and cognitive therapy is provided to all patients. In this treatment, the developmental stages of processing information, building learning skills and expressing emotions are retraced. Remedial techniques are used to strengthen weak areas and to rehabilitate lagging functions.

Child and adolescent psychiatry residents and staff provide 24-hour on-call services, which include emergency and crisis consultation services for all hospitalized McLean patients. Night call duties are described in a later section “On-Call Duties: Years 1 and 2” (see page 62).

Residents may elect to follow one or two cases discharged to an aftercare facility on the McLean grounds, which might include the Partial Hospital Program, the Adolescent Day Service, the Arlington Day School and/or the Outpatient Clinic. They also may choose to follow discharged patients at MGH. Under supervision, this experience will provide the resident an opportunity to engage in a variety of aftercare settings and to participate in the child and family’s continuity of care.